The decision to initiate maintenance dialysis for older veterans with end-stage renal disease affords one of the greatest opportunities to improve value in specialty care. Similar to other intensive procedures performed near the end of life, there are wide regional variations in the utilization of dialysis among older adults, suggesting that intensity of treatment for end-stage renal disease is determined by practice style or the supply of medical resources rather than the likelihood of benefit. The goal of this project is to determine the sources of variation underlying the decision to initiate dialysis and to identify specific patient, provider and facility characterstics associated with receipt of dialysis versus conservative (non-dialytic) care. This project will also compare the survival and health resource utilization patterns of dialysis versus conservative care management strategies. To accomplish this goal, we will assemble a national cohort of veterans approaching end-stage renal disease using VA claims data, laboratory records and detailed chart review. The findings from this project will inform the design of interventions and VA policies that promote appropriate use of dialysis.